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Mlne Salety and Health Atlminlstrati n <br /><<~ <br />Section I-Violation Data <br />} Dale Mo <br />QS Da <br />02 Vr <br />9D 2 Time 124 Hr Clockl <br />/ <br />~ 3. Citafio <br />odmee, <br />3630828 <br />erved T t <br />1 5. O or <br /> <br />i <br />6. Mine 7. Mine ID <br />D <br />~ <br />Z <br />(Contractor) <br />8. Con nor Practice <br />Ba. rtten Notice (10391 ^ <br />98~ r <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />See Continuation F rm IMSHA Form 7000~3a) ^ <br />9. Violation A. Health <br />Safety ^ <br />Other ^ B. Section <br /> <br />of Act _ <br />C. Part/Section of <br />Title 30 CFR <br />~ <br /> <br />~ <br />/ <br />~ <br />/ <br />/ <br />Section II-Inspector's Evaluation <br />10. Gravity: <br />A. Injury or Illness (has) (is). No Likelihootl^ Unlikely Reasonably Likely^ Highly Likely ^ <br />Occurred ^ <br />B. Injury or Illness could rea~ <br />sonably be expected to be: No Lost Workdays^ Lost Workdays or Restricted Duty^ Permanently <br />isabling^ Fatal <br />C. Significant and Substantial (See Resersel: Yes ^ No~ D. Number o Persons Affected D O <br />11. Negligence (check onel <br />A. None ^ B. Low ^ C. Moderate D. High ^ <br />E Reckless Dlsrega rtl ^ <br />12. Type of Action <br />I <br />~ <br />¢ <br />~ 13. Type of Issuance (check onel <br />Citaticn~ Order ^ <br />Safeguard ^ <br />14. Initial Action <br />D. Written <br />A. Citation^ B. Order ^ C. Safeguard ^ Notice ^ E Citation/ <br />Order <br /> <br />Number F. D ted Mo Da Vr <br />15. Area or Equipment <br /> <br /> <br />16 Termination Due <br />A Date Mo <br />Q Da <br />~~ QyrT <br />/ U B Time 124 <br />Hr. Clockl <br />O <br />S <br />a <br />Section III-Termination Action <br />17. Action to Terminate <br /> <br /> <br /> <br />18. Terminated Mo <br />A. Date Da Vr <br />B. Time (24 Hr, Clockl <br />Section IV-Automated $Yi[em Data <br />19. Type of Inspection <br />lactivity c el O / 20. Even( Number Q 3 ~ 21. Primary or Mill <br />22. Sig i/ 23 AR umber <br />MJMA roan /UUUJ, Mar B9 I rtevpegl <br />